Journal of The Korean Society of Clinical Toxicology

Volume 8(2); 2010

2008 Database of Korean Toxic Exposures: A Preliminary Study: Byung-Hak So, Mi-Jin Lee, Hyun Kim, Jeong-Mi Moon, Kyung-Hye Park, Ae-Jin Sung, Seok-Ran Yeom, Seong-Beom Oh, Ji-Young You, Kyung-Woo Lee, Kyung-Won Lee; J Korean Soc Clin Toxicol. 2010;8(2):51-60. Published online December 31, 2010

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Abstract PDF: Purpose: The aim of this study was to investigate toxic exposures in emergency centers with using a toxic exposure surveillance system-based report form as a preliminary study. Methods: We retrospectively reviewed the medical records of toxic exposure patients who visited emergency centers from January to December 2008. Results: 3,157 patients from 11 emergency centers were enrolled. Males were involved in 47.9% of the total cases of exposure and in 60.1% of the cases of fatal exposure. Suicidal intent was the most common (61.0%) reason and most (87.4%) fatal exposures were suicidal. Pesticides were involved in 30.7% of the cases and sedative/hypnotics/antipsychotics were involved in 20.5%. The substances most frequently involved in fatalities were pesticides, and a 48.4% fatality rate was recorded for paraquat exposure. Conclusion: The toxic exposure data showed the preliminary poisoning events in emergency centers. It is recommended that toxicology professionals should develop a toxic surveillance system and serial reporting should be performed.

Characteristics of elderly patients with acute poisoning: Bo-Kyeong Kim, Si-Young Jung, Koo-Young Jung; J Korean Soc Clin Toxicol. 2010;8(2):61-68. Published online December 31, 2010

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Abstract PDF: Purpose: Poisoning is a major health problem for the elderly, and poisoning can cause fatal side effects. However, the characteristics and clinical features of elderly patients with acute poisoning have not been well studied in the previous domestic research. So, we tried to analyze the clinical characteristics and toxic substances of the patients who were 65 years old or older and who were admitted to the regional emergency medical center due to acute poisoning. Methods: We retrospectively reviewed the medical records and poisoning protocols of the patients who were 65 years of age or older and who had with acute poisoning and who visited the ED in our emergency center from January 2005 to December 2009. We collected the demographic information, the gender, the underlying diseases, the causes and toxic substances, the initial presentation, the treatment and the outcomes. Results: A total of 2179 poisoned patients visited the hospital during 5 years, and among them 244 were 65 years of age or older (11.2%). The mean age was $75.6{pm}6.9$ years and the male:female ratio was 1:1.7. The most common cause of poisoning was suicide (73.4%) and the most common source of poisonous substances was their own drugs. Of the substances used for poisoning, benzodiazepine was the most common drug (25.8%), followed by sedatives other than benzodiazepine (25.4%), insecticide (12.7%), chemical agents (12.3%) and herbicides (8.2%). The most common initial presentation was mental change (64.8%). When comparing the factors between the three elderly groups, there was no difference in gender, the cause, the substances and the underlying disease. The outcomes of treatment included ICU admission (56.1%), a good condition at discharge (12.7%) and admission to a general ward (12.7%). The overall mortality rate was 10.2% for the elderly patients. Conclusion: In this Korean study, unlike the foreign studies, the most common cause of poisoning in elderly patients was intentional poisoning. The admission rate was 68.8% and mortality rate was 10.2%.

Clinical Comparison of Acute Poisoning Victims Between Urban and Rural Areas: Sang-Gil Kim, Kyung-Won Lee; J Korean Soc Clin Toxicol. 2010;8(2):69-78. Published online December 31, 2010

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Abstract PDF: Purpose: The living standards vary between the urban and rural areas in Korea. This study aims to compare the characteristics of acute poisoning victims in urban and rural areas. Methods: A retrospective study was conducted over a period of 2 years from 2008 to 2009. The study group included adults over 19 year old with acute poisoning and who were later were admitted to the local emergency medical center located in Daegu, Korea. The exclusion criteria were 1) the victims of adverse effects of therapeutic doses of drugs, 2) the victims with chronic exposure and 3) the victims who were missing data in their emergency medical records. We divided the victims into the adult group (19-64 years old) and the old group (over 65 years old). Results: There were 569 acute poisoning victims during the study period, and they constituted 1.11% of the total ED visits (51,199). Four hundred seventy six patients were enrolled in this study. Out of the 359 acute poisoning victims, 252 victims were from urban areas and 107 victims were from rural areas. They showed statistical differences for gender, ED access, transport, toxins and the time to the ED. In the old group, 61 victims out of 117 were from urban areas and the remaining 56 victims were from rural areas. They showed statistical differences for gender, ED access, toxins and transport. Conclusion: Through the clinical comparison between the acute poisoning victims of urban and rural areas, we exposed the clinical differences between the urban and rural areas, and we concluded that prevention and education for acute poisoning should be generated differently between the two groups.

Comparative Analysis of Overdose with Common Sleep-aid Medications - Doxylamine vs Diphenhydramine -: Hyun-Sik Ryu, Mi-Jin Lee, Seong-Soo Park, Won-Joon Jeong, Hyun-Jin Kim; J Korean Soc Clin Toxicol. 2010;8(2):79-87. Published online December 31, 2010

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Abstract PDF: Purpose: The previous studies on $H_1$ antihistamine overdose have generally been limited to cases of acute doxylamine succinate (DS) poisoning, yet there have been some studies on diphenhydramine (DPH) overdosing. But many clinicians consider the two drugs to be very similar and to have similar ingredients. The purpose of this study was to clarify the toxicologic characteristics and clinical outcomes between DS and DPH poisoning/overdose. Methods: We reviewed the medical and intensive care records of the patients with acute DS or DPH poisoning and who admitted to our emergency department from January 2008 and April 2010. We collected patient information regarding the features of the poisoning and the clinical and demographic characteristics. The patients were assessed for the clinical outcomes, the GCS, the PSS (Poisoning Severity Score) and the SOFA (Sequential Organ Failure Assessment). Results: Fifty seven patients (45 cases of DS poisoning and 12 cases of DPH poisoning) were enrolled. Compared with the DS group, the DPH group had higher incidences of intubation, serious mental change, QTc prolongation and ECG conduction abnormality (p=0.041, <0.001, 0.014 and 0.044, respectively). The DPH group had a higher PSS and a longer ICU stay. The peak CPK time and the CPK normalization time were longer for the patients with rhabdomyolysis due to DS poisoning. Conclusion: Two common $H_1$ antihistamines, doxylamine and diphenhydramine, are in the same ethanolamine-structural class, but the toxico-clinical outcomes are different according to many aspects. Therefore, clinicians could take a careful approach for the differential diagnosis and management between DS and DPH poisoning.

The Clinical Features and Risk Factors of Seizure After Doxylamine Intoxication: Beom-Soo Song, Ki-Man Lee, Sun-Wook Kim, Je-Sung You, Tae-Nyung Chung, Yoo-Seok Park, Sung-Phil Jung, Hong-Du Goo, In-Cheol Park; J Korean Soc Clin Toxicol. 2010;8(2):88-96. Published online December 31, 2010

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Abstract PDF: Purpose: Doxylamine is antihistamine drug that is used as a hypnotic. It is also used for suicidal attempts because it can be easily purchased at the pharmacy without a prescription. There were many articles about the complications after doxylamine intoxication such as a rhabdomyolysis, but only a few articles have reported on seizure. We reviewed the cases of doxylamine intoxication with seizure that were treated in the emergency department. Methods: We reviewed the medical records of the patients who were over 15 years old and who were intoxicated by doxylamine at 3 emergency medical centers from January 2006 to June 2010. We reviewed the patients' age, gender, the dose of doxylamine ingested, if gastrointestinal decontamination was done, the time from intoxication to hospital arrival, the seizure history, treatment of seizure, the electroencephalography (EEG) results, the brain computed tomography (CT) results and the blood test results. Results: There were 168 patients who were intoxicated by doxylamine during the study period. Twelve patients had a seizure episode. The differences between the patients who developed seizure and the patients who did not were the dose and the serum levels of sodium and creatinine. The only clinically meaningful difference was the amount of doxylamine. The amount of doxylamine ingested (>29 mg/kg) predicted the development of seizure with a sensitivity of 75% and a specificity of 92% on the ROC curve. One patient among the seizure patients expired in the emergency department. Conclusion: In case of doxylamine intoxicated patients, there is close relationship between seizure and ingested amount, so close observation needs to be done for the patients who ingest too much because doxylamine can cause death. Further prospective studies are needed for doxylamine intoxicated patients with a seizure episode.

Cardiac Toxicity in Patients with Antidepressant Intoxication: Jung-Taek Park, Se-Min Choi, Young-Min Oh, Joo-Suk Oh, Yeon-Young Kyoung, Hang-Joo Cho, Kyoung-Ho Choi; J Korean Soc Clin Toxicol. 2010;8(2):97-105. Published online December 31, 2010

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Abstract PDF: Purpose: Although cardiac toxicity is a key parameter of significant toxicity, in antidepressant intoxication, there are few studies on the cardiac toxicity of serotonin reuptake inhibitor and the intoxication with the new generation of antidepressants. The aim of this study is to investigate the relative cardiac toxicity of serotonin reuptake inhibitor and intoxication with the new generation of antidepressants as compared with that of tricyclic antidepressant intoxication. Methods: We retrospectively reviewed the medical records of 109 antidepressant intoxicated patients who visited the Emergency Department from January, 2005 to December, 2009 to collect and analyze the demographic and clinical data. Sixteen patients were excluded. The enrolled seventy eight patients were classified into three groups: the tricyclic antidepressant group (TCA) (n=32), the selective serotonin reuptake inhibitor subgroup (SSRI) (n=28) and the new generation antidepressant subgroup (NGA) (n=18). Results: The demographic and clinical data of the SSRI and NGA groups were not significantly different from that of the TCA group. The QRS duration of the SSRI subgroup ($86.4{pm}12.0$ msec) and the NGA subgroup ($91.8{pm}11.9$ msec) was not significantly different from that of the TCA group ($90.0{pm}13.5msec$) (p=0.598). The QTc interval of the SSRI group ($444.5{pm}33.5msec$) and the NGA group ($434.9{pm}35.9msec$) (p=0.260) were not significantly different from that of the TCA group ($431.2{pm}44.1msec$) (p=0.287). Conclusion: Intoxication with SSRI and the new generation antidepressants seemed to show significant cardiac toxicity, like what is seen in tricyclic antidepressant intoxication. Clinicians must pay attention to SSRI and new generation antidepressant intoxication.

The Factors that Predict Using Mechanical Ventilation for Patients with Organophosphate Intoxication: Dong-Chan Park, Jung-Bae Park, Yun-Jeong Kim, Soo-Jeong Shin, You-Ho Mun, Sin-Ryul Park, Hyun-Wook Ryoo, Kang-Suk Seo, Jae-Myung Chung; J Korean Soc Clin Toxicol. 2010;8(2):106-112. Published online December 31, 2010

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Abstract PDF: Purpose: The purpose of this study is to investigate the factors that predict using mechanical ventilation for patients with organophosphate intoxication. Methods: We retrospectively reviewed the medical records of 111 patients with acute organophosphate intoxication and who were treated in our emergency center from January 2000 to December 2008. We compared the toxicologic characteristics, the laboratory findings and the APACHE II scores between the Mechanical Ventilation group (MV group) and the non-Mechanical Ventilation group (the non MV group). Results: Sixty three patients were in the MV group and 48 patients were in the non MV group. In the MV group, the patients had an older age (p<0.001), a larger amount of ingestion (p<0.001), a lower initial serum cholinesterase level (p=0.003), a higher APACHE II score (p<0.001) and they ingested a more toxic agent (p=0.001). There were no significant differences in gender, the type of visit and the arrival time between the MV group and the non MV group. Conclusion: We suggest that the patient's age, the amount of organophosphate ingestion, the toxicity of the agent, the initial serum cholinesterase level and the APACHE II score are important factors to determine if mechanical ventilation will be applied for patients with organophosphate intoxication.

Drug induced Pulmonary Edema: Si-Han Sung, Hye-Young Jang, Hoon Lim; J Korean Soc Clin Toxicol. 2010;8(2):113-121. Published online December 31, 2010

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Abstract PDF: Purpose: Drug-induced non-cardiogenic pulmonary edema has been reported on in a drug case series. For most of the agents that cause pulmonary edema, the pathogenic mechanisms that are responsible for the pulmonary edema remain unknown. We report here on the cases of suspected drug-induced pulmonary edema and we analyze the clinical characteristics. Methods: We reviewed the medical records of 1,345 patients who had drug adverse effects and drug poisoning from January 2005 to July 2010, and 480 of these patients were admitted to the EM Department. Among them, 17 patients developed abnormal chest radiological findings and they were analyzed for any clinical characteristics, the initial symptoms, securing the airway and the clinical results. Results: Seventeen patients out of 480 (3.54%) developed drug-induced abnormal chest radiographic pulmonary edema; they displayed initial symptoms that included mental change (41.2%), dyspnea (17.6%), vomiting (11.8%), etc, and some displayed no symptoms at all (11.8%). Only 3 patients out of the 11 who died or had severe pulmonary edema were able to obtain an advanced airway prior to their arrival to the EM Department. Clinical recovery was generally rapid and this was mostly completed within 6 hours. The mortality rate was 11.8% (2 of 17 patients), and the causative drugs were found to be propofol (35.3%, 6 of 17 patients), multiple drugs (41.2% or 7 out of 17) and one patient each with ephedrine, ethylene glycol, doxylamine and an unknown drug, respectively. Conclusion: Drug-induced pulmonary edema and deaths are not uncommon, and recovery is typically rapid with few long-term sequelae when drug administration is discontinued. Oxygen therapy and securing the airway must be performed during transportation for patients with pulmonary edema.

A Case of Bentazone Poisoning Mimicking Organophosphate Intoxication: Hyun-Min Jung, Ji-Hye Kim, Seung-Baik Han, Jin-Hui Paik, Ji-Yoon Kim, Jun-Sig Kim; J Korean Soc Clin Toxicol. 2010;8(2):122-124. Published online December 31, 2010

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Abstract PDF: $Basagran^{(R)}$ is a herbicide that is widely used in the field and it acts by interfering with photosynthesis in plants. It consists of bentazone, 2-methyl-4-chlorophenoxyacetic acid (MCPA) and surfactants. Bentazone is commonly used, but poisoning due to Bentazone has not been previously reported in Korea. The patients with toxic effects of bentazone show mild to severe symptoms and various complications. We report here on a case of a woman who intentionally ingested 500 ml of $Basagran^{(R)}$ and she was discharged without complication. As soon as the patient visited the emergency department, we started to treat her as if she had organophosphate intoxication because of the cholinergic symptoms. We could not detect the bentazone in her serum and urine, and we could confirm $Basagran^{(R)}$ ingestion only after getting information from her husband. Bentazone poisoning may induce harmful complications like muscle rigidity, rhabdomyolysis, respiratory failure and cardiac arrest. A detailed history taking, an accurate analysis method and early conservative management will be helpful for patients with acute bentazone poisoning.

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